An Appeal Sample Clauses

An Appeal. (C) A request for an External Appeal. In each of these review processes, Your notice to Us is considered to be filed on the date We first receive it orally or in writing. Detailed information on how to submit all of the above may be found in this Contract, on Our website, in newsletters, and in medical management determination letters sent to Enrollees when a Health Service is denied. At least annually in a newsletter, We notify Enrollees about the Grievance and Appeal process and the availability of External Appeals. Neither You nor Your Designated Representative will be subject to retaliation from Us for exercising Your rights to any of the review processes described in this Article. Also, We may not take any action against a Provider solely on the basis that the Provider represents You in any of the review processes described in this Article.

An Appeal. You can ask us to re-review an adverse benefit determination. This is called an appeal. You can appeal to us verbally or in writing. Claim decisions and appeal procedures Your provider may contact us at various times to make a claim, or to request approval for payment based on your benefits. This can be before you receive your benefit, while you are receiving benefits and after you have received the benefit. You may not agree with our decision. As we said in Benefit payments and claims in the How your plan works section, we pay many claims at the full rate, except for your share of the costs. But sometimes we pay only some of the claim. Sometimes we deny payment entirely. Any time we deny even part of the claim, it is an “adverse benefit determination” or “adverse decision.” For any adverse decision, you will receive an explanation of benefits in writing. You can ask us to review an adverse benefit determination. This is the internal appeal process. If you still don’t agree, you can also appeal that decision. There are times you may skip the two levels of internal appeal. But in most situations, you must complete both levels before you can take any other actions, such as an external review. Appeals of adverse benefit determinations You can appeal our adverse benefit determination. We will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. Aetna will handle all first level appeals. You can appeal by sending a written appeal to Member Services at the address on the notice of adverse benefit determination. Or you can call Member Services at the number on your ID card. You need to include: • Your name • The employer’s name • A copy of the adverse benefit determination • Your reasons for making the appeal • Any other information you would like us to consider Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form by contacting us. You can use an authorized representative at any level of appeal. You can appeal two times under this plan. The plan sponsor will handle all other level of appeals after the first level. ...